Am homeless - shelter, car, outdoors, or transient (moving from place to place) OR I am soon to be homeless due to eviction notice, behind on bills, and/or other reasons Have a temporary living arrangement but seeking permanent housing Have adequate, permanent housing

HOUSING REHABILITATION

Today: (choose one that best fits)
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I am seeking repairs to my place of residence I am able to fix my housing repairs on my own My place of residence is not an issue

FINANCIAL SECURITY

Today I: (choose one that best fits)
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Have limited financial resources due to no income or inadequate income Am employed and utilize public assistance (TANF, SSI, SNAP, Food Pantry, Public Housing/Section 8, etc.) Am financially stable - can pay bills and have savings

EDUCATION

Mark the one that best applies to yourself or a family member:
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I or someone in my immediate family does not have a high school diploma/GED and/or needs education and training guidance I or someone in my immediate family is currently receiving assistance and working towards education goals No family members have educational needs or concerns

EMPLOYMENT

Choose one that best fits:
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I need a job and/or assistance with job readiness and job search I am underemployed or at risk for losing my job or employment is not an option right now I have stable employment and I am not seeking employment assistance

TRANSPORTATION

Today I: (choose one that best fits)
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Have no transportation and no access to public transportation Have transportation to cover basic needs, though it is limited Have reliable transportation and no transportation needs

EARLY LEARNING AND CHILDCARE

Choose from the following:
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I need to enroll my child(ren) in an early learning program and/or childcare facility My child(ren) is enrolled in early learning/childcare but it is not affordable and/or reliable I have no early learning or childcare needs

Is there anything else you would like to tell us about yourself or your family to better serve you? (Check all that apply)
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I am in need of assistance due to domestic violence or personal safety concerns I am in need of assistance due to mental health issues with myself or a family member I am in need of assistance due to substance abuse issues with myself or a family member I am in need of assistance due to health issues with myself or family member I am interested in improving my parenting skills I am interested in financial literacy classes I am interested in volunteering I am interest in learning about social and educational opportunities for my child or teenager I am in need of medical assistance/health insurance Other option

OTHER

SECTION 3 - MISCELLANEOUS

Where did you complete this form?
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LCCAP facility Place of residence Mobile device Public location Shelter Other option

Lawrence County Community Partnership is committed to linking customers to the services and resources available throughout our agency and community.
I hereby certify that to the best of my knowledge, the information contained herein is true, correct, and complete. I agree to report any changes in circumstances immediately to this service provider. By typing your name and date below, I give permission for an LCCAP representative, to contact me to provide additional information, resources or support related to my responses.